© NSW DET 2009
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Reading 5: Complete reporting and documentation
Introduction
Comply with the organisation’s reporting requirements, including reporting observations to supervisor
Complete documentation according to organisation policy and protocols
Maintain documentation in a manner consistent with reporting requirements
File documentation according to organisation policy and protocols
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© NSW DET 2009

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This topic will provide an overview of workplace documents, forms and files which must be completed, stored and maintained in accordance with policies and protocol of the organisation.
By completing this unit, you will learn how to comply with the organisation’s reporting requirements including reporting observations to supervisor. You will also find out how to complete and file documentation according to organisation policy and protocols. Additionally, there will be an opportunity for you to gain knowledge of how to maintain documentation in a manner consistent with reporting requirements.
In the community services and aged care industries you will be required to provide ‘hands on care’ to your clients You will also have to fill in forms, write reports on the support and care given to clients as well as give verbal reports.
Imagine having to look after an elderly person with multiple medical, physical and psychological needs without any form of documented information about this person. Providing proper care would be an impossible task. What if your client has fallen? They may have many different care needs as well as require the services of a physiotherapist and
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4 an occupational therapist in addition to their usual treating medical officer.
A number of people may have input into this client’s needs.
Feedback
The only way to help guarantee an excellent standard of individualised care is if everyone who cares for the client, passes on current verbal and written information to one another. This information includes various assessments, as well as a plan of care that incorporates changes in care needs such as illness, a fall, constipation, or changed behaviour. An understanding of health records and associated documentation is therefore critical to your work role. These records give you and the team, the necessary information to provide relevant care for your clients.
An understanding of health records and associated documentation is therefore critical to your work role. These records give you and the team, the necessary information to provide relevant care for your clients.
Every client in the community services and aged care industries has their own health or service record to document information regarding the care provided as well as any incidents which may occur, such as falls. It is also sometimes called a ‘client or resident file’, ‘resident records’, ‘charts’,
‘clinical file’, ‘histories’, and ‘medical files’. These records contain vital information about the client.
Reports and records are used for a wide range of purposes. The primary purpose of documentation however, is to ensure quality outcomes for clients. The Commonwealth Department of Health and Ageing,
Documentation and Accountability Manual (1997 4.2) states that effective documentation provides the primary evidence for the provision of quality care to residents. This Manual outlines the key functions of residential aged care clinical records and is available online at available at: http://www.health.gov.au/acc/manuals/dam/chapt4.htm
Generally, the purposes of documentation include:
 assessing needs and recording information about clients to help plan, implement and evaluate appropriate services
 recording actions
 explaining why we did something
 reminding us of what we need to do next
 reporting incidents such as falls and documenting any subsequent actions
 referring clients
 providing information to external agencies eg a court report
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© NSW DET 2009
 planning work or programs
 advocating for clients and seeking information
 facilitating communication between workers
 developing policy and procedures
 taking minutes of meetings
 providing information to clients about our service and their rights
 advertising services
 lobbying governments or other agencies
 consulting with the community to identify needs
 researching issues and education
 writing funding proposals
 financial management
 providing feedback to funding bodies
 providing evidence of accountability, accreditation and/or quality outcomes
 conveying ‘bad news’
 responding to complaints
 making a complaint.
This list is not all-inclusive. You can see that documentation is instrumental in providing a quality service. Written documentation helps communication between staff and with clients. It also impacts directly on the financial and human resources of the organisation.
In the aged care industry, care records assume a central position in the process of government funding, accreditation and quality monitoring. It is important to understand the standards relevant to your organisation and work role. Standards outline exactly what is required of you and you must comply because your organisation’s ongoing success depends on it.
You will be required to document falls and write down how your client has been affected by a fall. Understanding the basics of writing and verbalising reports are therefore very important.
Think about the information you gain when you are caring for a client during your shift and particularly if they have had a fall. Think about the information you may be expected to pass onto other people. Is there one way to do this or is there a number of ways that this can be done?
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Feedback
There are a number of ways that you can report what is happening to your client. You will be required to document care, as well as incidents such as falls, and write down how your client has responded to the care provided.
You may also be expected to informally provide feedback using communication tools such as diaries. There will also be opportunities to provide feedback face to face via handover reporting or on the telephone.
Understanding the basics of writing and verbalising reports is therefore very important.
Verbal reports are used to ensure the person taking over the client’s responsibilities (this could be other workers or the person’s carer) have information concerning the most current care needs of the person. Verbal reports are normally given at the start of each shift– handover or changeover report – when care needs have changed during a shift and when changes occur in a client’s condition or needs such as if they have had a fall with an injury. In the community, verbal reports may also be given over the telephone to the client’s medical officer or other health support or aged care workers.
Health support or aged care workers finishing their shift should also give a verbal report of any tasks or care not completed for clients to the person taking over their responsibilities. You may be required for example, to contact a General Practitioner and advise them of a client who has fallen and sustained an injury.
All verbal reporting should be:
 clear
 accurate
 concise (to the point)
 factual
 objective (what you actually see and hear not what you feel or think).
Staff receiving a verbal report should clarify points if they are not clear or they do not understand.
There are many different ways of reporting verbally:
 informing your supervisor of changes in a client’s condition and/or needs
 relaying messages
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 meal-break handover
 end of shift – handover/changeover report
 enquiries about the client
 telephone conversations including informing General Practitioners of changes the client is experiencing.
 case/team conference.
As a health support or aged care worker you will have access to confidential and personal information. Generally, it is not part of your role to give callers any information of a confidential nature. (Always check your role statement and the organisation’s policies to ensure you are aware of correct procedures.)
Examples of confidential information are:
 client details and medical condition
 worker’s home address and/or telephone numbers (if they are not in the public domain ie in the white pages)
 a client’s financial details.
 injuries sustained as a result of a fall
Confidentiality during handover reports or telephone conversations must be upheld. You must be mindful of the legal implications surrounding reporting and recording of client’s health care information, so there is not a breach of a client’s privacy rights. It is difficult for example to ensure confidentiality of information if the verbal handover report is given in an area where visitors may pass.
Remember, when families are trying to get information about a client who has fallen, they may be quite stressed and very demanding until they know the full details of what has happened and whether or not the client has been injured. You have a responsibility and duty of care to ensure that the information you provide remains accurate but does not breach your client’s confidentiality.
Observing clients is a vital part of the health support or aged care worker’s role. To be able to report changes in a client’s condition or needs, the carer must be a good observer. To observe people in your care, you must use ALL your senses. Observing is much more than just looking at the person.
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Anything unusual or out of the ordinary should be noted and reported to the supervisor. For example, you may smell a strange odour, hear a moan or groan or feel an unusual swelling or lump on the skin. Sometimes you will hear a moan only to find that the client is lying injured on the floor with their walking frame on the other side of the room. It is important to remember these observations when the fall is being analysed so that the cause of the fall can be determined accurately. The person finding the fallen client may not be the one undertaking the fall analysis, therefore it is critical that information such as this is clearly documented.
It is important to know your client to be effective in the care you give.
‘Care’ includes being attentive to change and reporting any changes to the relevant person. The health support or aged care worker must first know what is ‘normal’ before they can recognise what is not normal. The age, gender and known medical condition and diagnosis of the client must be kept in mind.
It is good professional practice to establish an organised way of observing.
Assisting clients with personal hygiene is a good opportunity to observe skin integrity, communication skills, orientation to time and date for example, and any changes in behaviour. Transferring clients from one position to another can provide an opportunity to observe mobility. If you are not watchful during all interactions with clients then changes will be missed.
Why should aged care workers ask clients/residents questions about what activities they are interested in on a regular basis? Why is it important to discuss emotional and social needs in private?
Feedback
It is important to enquire about client’s interest on a regular basis because people’s interests and abilities change all the time and it is vital to be in touch with clients about these matters.
If we want truthful answers about how people are going emotionally, socially and/or sexually, then we need to discuss this in private.
There are many types of reports a health support or aged care worker may use to document relevant information when working with a client. The organisation you work for will provide you with training about the documentation available and their expectations regarding written reports.
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© NSW DET 2009
What is written is permanent as soon as it is placed on paper and saved to computer, therefore it is difficult to change or retract. In some cases, written work documents need to be kept for 15 years.
Reports should be brief and complete. In other words, while all important issues need to be documented, ‘padding out’ of the health record should be avoided. If a client has fallen, it is important for example, to include this in the client record as well as any injuries that may have been sustained. It is not necessary however to include a discussion that the client may have had with a visitor immediately prior to fall unless, of course, that is why the client fell.
Health support or aged care workers are responsible for documenting the care they provide and for gathering information about a client to assist in the development of care plans. As outlined by the Commonwealth Department of Health and Aged Care (1999), use of the senses of perception, observation, sight, hearing, touch and smell can assist in gathering appropriate information.
Documentation should occur at the time of, or as soon as practicable following the provision of a service, observation, assessment, diagnosis, management, treatment, professional advice, or any other matter worthy of note (NSW Policy Directive 2005_127 pp. 4). This is particularly important if a client has fallen and sustained an injury. In some instances the client may have to be transferred for medical treatment and if you have been slow to document what has happened, crucial information about the fall may be missed.
Health support or aged care workers are often responsible for documenting in the client’s Progress Notes. Some organisations expect their workers to make entries based on ‘exception’ or ‘exceptional reporting’. This means that only significant changes to standard care are documented rather than repeating the same information in each report. Exceptional reporting is dependent on comprehensive individual care plans which outline the standard of care to be provided. An exceptional circumstance is anything that is unusual and is not already in the resident’s care plan. This may include changes to the care or incidents such as a fall which have occurred during your shift. It is only necessary to record things in the progress notes at the end of each shift which are not already included in the standard care plans (Whitney et al 1997).
If, at 1000hrs, you provided exercises according to the care plan you may write ‘Care provided according to care plan’. You may have witnessed a client slip in the shower however, then it is acceptable to write ‘slipped whilst showering’ but if they are injured you would also need to include
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10 this. If you observe a bruise on the client and the client tells you they fell, you may write ‘small bruise, approximately the size of a fifty cent piece observed on the client’s forehead, just above the left eye. Client advises they slipped when going to the toilet overnight’. You would also need to talk with the client about ways to avoid this occurring again and ensure this information is also documented.
There are many factors which need to be considered when filling out forms and documents. It is important that they are filled out in accordance to the organisation’s protocols and procedures so it’s very important that you become familiar with your organisation’s requirements.
Good quality writing underpins effective documentation. Good writers plan the writing task. They clearly understand the purpose of the document and draft what they will write, analyse the reader and their needs, write in plain
English, use acronyms approved by the organisation and language appropriate to the reader and the context. They also collect the necessary information and carefully edit the finished product.
Writing in plain English means using simple or commonly used words instead of complicated ones. Often writers use complicated words because they think that if the words look impressive, they will look impressive.
If you use plain English, your writing has a much better chance of being understood and thus you are more likely to achieve your purpose.
Good writing doesn’t just happen. You need to practise and get feedback on your skills.
Good documentation will help you defend yourself if there happens to be an investigation into an incident. This investigation may be carried out internally within the organisation or externally involving police, Coroner, or a law court if the incident involves criminal charges or a civil law suit.
Think about all the different ways of writing. How would you write a text or
SMS message for example? How is this different to writing about a client you have just provided care for?
Feedback
Text or SMS messaging is all about keeping the message as brief as possible, taking the least amount of time to write the information and the information is not expected to be kept for long periods of time or become an example in a court of law. Client records however are meant to describe in detail what has occurred for the client, must be kept for long periods of time
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© NSW DET 2009 and may be used in a court of law. There are therefore, certain standards for recording and reporting client information.
Requirements of written reports
The expected standard of recording and reporting must meet the following requirements.
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They must be legible with correct spelling and grammar. If your handwriting is unclear or difficult to read, then it is advisable to print your reports.
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They must be written in plain ENGLISH.
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The year, date and time must appear on each entry.
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The record must clearly identify on each page the client’s: o family name o first name o date of birth o medical record or client number (if applicable).
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Sign all entries with your designation, with the name printed at the end of each written report by the person authorised by the facility.
Examples of designations include: registered nurse (RN), enrolled nurse (EN), assistant in nursing (AIN), care service employee (CSE), general services officer (GSO)
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Write in black pen (as per Australian Standard 2828).
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They must be stored for seven years after the person ceases to receive services.
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Never write what someone else said, heard or smelled.
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Write client care and events as soon as possible after they occur.
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Chart precautions or preventative measures such as ‘assisted out of bed by two carers’, or the use of bed rails.
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Do not chart ahead of time.
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If you wish to add something to the notes after the entry has been made and signed, add an extra entry by writing ‘Addit’ before the entry.
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Do not alter a client’s record – it is a criminal offence.
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Use the 24-hour clock.
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Before you write in the client’s file, ensure it is the correct file.
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Only use accepted abbreviations and terminology.
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Every line must be filled either with words or a line – this is to prevent information being added.
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Always read previous entries in the progress notes.
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Don’t use jargon or abbreviations.
Client records are legal documents and jargon and abbreviations can be misunderstood. An organisation would not want an entry in a client record misinterpreted if it is being discussed in a court of law.
Taking a telephone report may be necessary to relay information to a client, their relatives/significant others, other health support or aged care workers.
You may be giving information such as a simple clarification of a client’s condition or the family may have to be contacted following a critical event such as a fall with a head injury.
Things to do:
 always answer the phone politely and pleasantly
 slowly and clearly state who you are
 write down a rough outline of the message
 repeat the message back to the caller to confirm the details
 be helpful by making suggestions if you cannot do what is being asked, eg. if a relative wants to speak to the supervisor, who has gone to lunch, suggest you could take the caller’s telephone number and have the supervisor ring them back after lunch
 always end the conversation politely, eg ‘Thank you for your call, good afternoon’
 ensure you pass on messages
 ensure messages are written in the communication book if they are relevant to all staff and/or documented according to the organisation’s protocols particularly if the information is related to client care.
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© NSW DET 2009

Handover reports are given at the change of each shift from outgoing to oncoming staff. Handover reports emphasise the important issues/events which have occurred for that shift, such as clients going for tests and the appropriate requirements or clients going on outings with their relatives or a client slipping or falling. They should also include abnormal observations
(temperature/BP etc) requiring monitoring and actions such as contacting the client’s medical practitioner.
Handover reports can take two forms:
1 live ‘face-to-face’ reporting to oncoming staff at the change of shift
2 tape recorded reporting for oncoming staff at the change of shift.
Things to do when receiving a handover report:
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Listen carefully.
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Take notes of the important points relevant to each client.
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Use symbols, eg up arrow temp, for increased temperature or down arrow eating for decreased appetite, to assist in gathering as much important information about each person for that shift.
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Politely interrupt to ask questions if you need to clarify issues from staff giving the handover report. It is better to interrupt a handover report than miss important information for appropriate care for that shift.
Things not to do when giving a handover report:
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Do not make subjective or judgmental comments about a client or their family members during handover reporting; you must reflect a professional attitude, with only objective and factual information being used to describe the management and care of a patient, client or their families/friends at all times.
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Do not make judgmental comments about a client’s cultural and or religious beliefs.
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Do not question a staff member about why they did not stop the fall from happening. The fall would need to be investigated in an appropriate manner.
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We all have different ways of expressing ourselves and how we write things down. Some people may choose to draw a picture of what has happened to a client. Another person may decide that the information they have is important to include in the client file whilst another person may decide it is not important enough to include. Imagine the impact that this could have on an organisation. Think about how confusing that would be for a person just starting out with an organisation.
Feedback
Organisations develop policies and protocols to provide a consistent way for staff to undertake their role as well as complete documentation.
Organisations usually have guidelines and procedures regarding:
 how to take messages
 how staff communicate in writing with each other and with clients
 how forms and reports should be written
 which forms to use for specific purposes
 who signs written documents
 who has authority to write on behalf of the organisation
 how incoming and outgoing correspondence is handled
 how quickly documentation needs to be completed
 how to store and protect private information.
To find out about an organisation’s policies:
 ask your supervisor or work based learning coordinator
 look at the organisation’s policy and procedures manual
 ask other staff members
 inspect current case files, letters, etc if you have permission.
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You have a responsibility to find out what the organisation expects and then abide by the rules. If you don’t agree with the organisation’s guidelines and procedures, you need to discuss your concerns with your supervisor.
Each aged care facility or organisation will have their own guidelines and protocol regarding documentation requirements for client health records.
They will also have their own guidelines and documentation for reporting and following up on falls. These guidelines help to direct you in the use of the appropriate forms required in your role of care health support or aged care worker as well as provide direction in how to document. Initially, it may seem a little daunting, but with some practice, documenting will become easier until it becomes a routine task requiring little effort.
Important organisational information with regard to health records involves:
 the safe storage of client health records
 security of health records
 types of forms to be used
 specific documentation requirements for example, each ‘group’ of professionals may be required to write their title prior to making an entry, such as ‘physiotherapist’ or ‘nursing report’
 confidentiality of information.
Policies and procedures provide security safeguards in organisations to protect the information of individuals, including clients as well as staff.
Reports are important as a means of providing an indication of a client’s status so that effective evaluation of care options can be planned and implemented. Reports may be written (hardcopy or electronic health care records) or verbal (in person during staff handover or as a telephone report to another health support or aged care worker). Reports that are inaccurate, do not have enough information, or include irrelevant information, may result in reduced funding and impact on client care. This is particularly so if falls are not documented for example. An expected standard by which aged care facilities are assessed during the auditing process is whether or not falls are documented and followed up to minimise the resident’s future risk of falls. For this reason, aged care facilities in particular are usually vigilant in their documentation and follow up of falls, falls assessments and falls minimisation strategies.
A good clinical or care record should contain at least the following elements:
 thorough documentation when the client is accepted by the service, including medical and social history and physical examination
 full assessment of care needs
 care plan or management plan
 completed medication chart if required
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 other relevant charts.
The structure and content of documentation and information in many organisations is moving from paper based records to a paper free workplace by electronic charting using computers. This form of charting may allow more efficient documentation to take place.
Written reports and workplace forms should be presented according to the
‘rules’ in the following table:
Table: ‘Rules’ of written reports
Clear
Concise
Write what you mean and mean what you write
To the point, do not ramble on – it’s not a story
Factual Write facts, for example ‘Mr Kim staggers when walking’ not ‘Mr Kim is drunk’
Complete Do not miss important information. Do not just write ‘c/o pain’, write what you did about it. ‘c/o pain in the left lower leg RN informed immediately’.
Accurate Accurate. If it is 1024 hrs, do not write 1030 hrs. Write ‘client found in wet bed –approx 250ml urine’ not ‘wet bed – large amount’
Relevant Only write what is relevant
Logical Ensure entries are logical, that is, they make sense
Objective Do not be subjective or emotional when writing, remain objective.
Useful Write information that others find useful to provide care. Do not write, for example, ‘Mr Kim sometimes has bad skin’. This entry is not useful without detail.
Specific Be specific when writing. For example, write ‘S/B Dr Wuthers’ not, S/B doctor.
Read the example of completed progress notes below. They provide clear information about the type of care given which is according to the nursing care plan. They also provide information about the client’s fall and what has been done in response and who has had made the entry. If you think about the information provided in the above table you will note that the entry is clear, concise, factual, complete, accurate, relevant, logical, objective, useful and specific.
Example of completed progress notes
PROGRESS NOTES
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17.6.09
17.6.09
MRN: 007311
Surname: Cordina Other Name: Maria
DOB: 26 March 1923
Doctor: Roper
Date
17.6.09
17.6.09
Time Notes
1010 All care given as per NCP.
S Ridley
(Ridley) Carer
1345 Heard resident calling out at 1315 hours and on investigation found Mrs Cordina lying on the floor near the bed. Pressed call bell to request assistance as fresh blood observed on floor and in.
Mrs Cordina’s hair. Stayed with resident. Assisted resident to
1630
1730 bed after initial review by RN. RN with resident at the time of the report.
S Ridley
(Ridley) Carer ____________________
Reviewed resident. 5cm laceration to back of head. Same. dressed with steristrips and dressing applied. Half hourly and then hourly observations attended. Neurological and general observations satisfactory. Conscious. Paracetamol given for headache at 1545 with good effect. Family informed. GP informed. M Lucindier (Lucindier) RN ____________________
Checked resident. States pain free. Conscious and talking with staff. Ate small amount of sandwiches for evening meal.
Observations satisfactory. F. Teangio (Teangio) RN
If you a documenting a social activity you should have include the time, location and date of the activity; the people involved; any observed interactions between clients and/or other participants; the general mood during the activity and any feedback received relevant to the activity.
Example:
Friday 13 th November, 2009, the residents of Grevillea Aged Care Facility went on a bus excursion to Green Valley Farm outside Tingha, leaving at
9.00am. They were accompanied by a registered nurse and two assistants in nursing and three family members provided additional support. During the bus trip, entertainment was provided by a guitarist and people sang along with her. Once the group disembarked, they proceeded to participated in all the activities, from feeding the animals to taking pictures. The picnic lunch was much appreciated. Everyone had a happy time and commented that they would like to return soon. C. Blacksmith
R.N
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Documentation is an integral component of reporting and has over time, become a more complex task for health support or aged care workers. As explained by Savvy (1997), documentation has a central role in the process of securing government funding and quality monitoring so all records that are part of this process are open to scrutiny.
The challenge health support or aged care workers face is to provide high quality direct care to clients whilst also providing high quality documentation. This documentation should provide adequate information for the planning, implementation and evaluation of a client’s care.
There are many factors to be considered when filling out forms and documents. It is essential that they are filled out in accordance with the organisation’s protocols and procedures so it’s very important that you become familiar with your organisation’s requirements. This is the case when a client has fallen. Often the organisation will have guidelines for strategies to be implemented and falls evaluation guidelines. Where these guidelines have been provided it is important to ensure they are used as per the organisation’s protocols.
As aged care or health support workers, we are accountable for the service we provide to our clients and the organisation for which we work. We are also accountable for keeping all forms and documentation up to date. One way of being accountable and ensuring care plans are the most accurate and appropriate is through record keeping.
Think about the type of information you include in reports. There is information about your client’s health and sometimes information about their finances. Not everyone wants this information to be known to other people. Imagine if you were a client and you read that you had a fall because you did not follow the strategies that were recommended. How do you think this would make you feel?
Feedback
Clients have the right to read an entry in their record and they are also a legal document. Therefore it is important to take certain things into consideration when record keeping.
There are a number of issues to be aware of in record keeping:
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Confidentiality: Information in these records of a person’s life will be very personal in nature. They should therefore be kept in a secure location where only those people who need to view the records can do so. The location where they are kept needs to be secure and access restricted.
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Language: Language used in these files should be non-judgmental and positive. Remember that the person who the records are about should be able to read them without feeling insulted. It is a good idea to keep records jargon free as well, so everyone who reads them will be able to understand them. Don’t forget your writing needs to be clear and legible as well. The organisation you work for may have standards that are required of you with regard to this.
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Identification : As previously mentioned, you are accountable, so records you are completing should clearly state your name and signature and the date. The order of the documentation should be arranged in an organised way so access to different forms is easy.
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Accuracy : Your records should only contain facts. If you include information about what you feel or believe, then you must state this.
Don’t use language such as ‘Joey doesn’t like working with Hamish’ because you observed Joey getting irritable with Hamish when working with him. Instead, you could state, ‘Today I observed
Hamish telling Joey to ‘shut up’ when Joey was talking with him’: this is fact. You could add, ‘I am concerned that possibly Hamish does not have the patience to work with Joey, I will need to investigate further’: this is a feeling.
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Including the person’s views and goals, and those of the significant others in their life : Make it easy for the person to have an opportunity to have their own entries in the records, and allow them to challenge and change entries you may have made. The client can do this if they have the cognitive ability to do so. If the client is not able to do this, then their legal representative may.
It is most important that the person consents to information being shared about them. Having the person or a responsible person sign a consent form acknowledges that permission has been granted to do so.
Health and community services records are permanent, legally accountable documents that must accurately record client needs, the actions of the health support or aged care worker/s concerned and general service delivery practices.
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As already mentioned, these records may be produced in court to substantiate or refute client claims, to support funding submissions, and/or to measure service outcomes and quality care provisions.
Organisations and agencies usually have guidelines and procedures about correct documentation methods including documentation to be undertaken when a fall occurs and also to minimise the risk of falls. Health support or aged care workers need to comply strictly with these organisational requirements.
If you don’t agree with the organisation’s guidelines and procedures, you need to discuss your concerns with your supervisor.
A poorly written published document can be very detrimental to the status of your organisation.
Documentation should occur at the time of, or as soon as possible after, the provision of care, observation, assessment, diagnosis, management, treatment, professional advice, or any other matter worthy of note. (NSW
Health PD 2005_127 p4)
When you record observations, be very precise in your descriptions and record what you actually saw, heard, smelt etc. For example:
I observed ‘Dawn’ put her walking stick across the path of Mark. Mark fell forwards onto the carpeted floor in the lounge room. He landed on his hands. Mark had no obvious injuries and advised that he was unhurt. I did not observe any aggressive actions from Mark, who had just walked into the room.
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We live in a society that is increasingly supportive of a client or their relatives taking legal action to gain compensation from civil and criminal proceedings, claiming negligence has occurred during or as a result of care, many years after the event. Poor documentation may therefore lead to a health support or aged care worker’s competence and credibility being questioned if there are obvious inaccuracies or omissions. It is very important for health support or aged care workers to acknowledge their role in providing quality information for reporting.
The client’s privacy is protected by law. There are numerous national, state and local statutory bodies that regulate the format of care records. The following Acts relate to the privacy and confidentiality of clients.
Health Records and Information Privacy Act 2002: This new Act commenced in July 2004. It protects the privacy of an individual’s health information, enables individuals to gain access to their health information and provides an accessible framework for resolution of complaints regarding the handling of health information.
The NSW Crimes Act 1900: There is an obligation for people who have information about serious criminal offences to notify the police. A serious criminal offence is an offence that attracts a penalty of five years imprisonment or more. Health support or aged care workers should be aware that this covers offences such as drug trafficking, serious assaults, sexual assaults, murder and manslaughter. It does not include minor possession offences or any offences under public health legislation.
The Privacy and Personal Information Protection Act 1998: This Act consists of internationally accepted privacy principles dealing separately with collection, storage, use and disclosure of personal information. One of the key principles stipulates that agencies must allow the client access to their personal information without unreasonable delay and expense.
Personal information includes information kept on client or agency records, personal details shared with you by the client and/or others, communications from other agencies or medical information given to you where the client has been referred to your service by a doctor or health practitioner.
Health Records and Information Privacy Act (2002), expects personal information in regard to residents:
 will not be unlawfully or improperly accessed
 will not be unlawfully or improperly disclosed
 will not be used other than for the purpose that it is intended for
 will be treated confidentially and sensitively
 will comply with the organisation’s security policy and procedures
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 official information, files, documents and computer files will be secured and locked so that no unauthorized access can be made
 staff will not disclose official information or documents gained from their official capacity outside of the organisation unless authority has been issued by the Director of Nursing or the Director of the organisation.
The NSW Policy directive PD2005_127 Principles for Creation,
Management, Storage and Disposal of Health Care Records available at: http://www.health.nsw.gov.au/policies/PD/2005/PD2005_127.html recommends that a health care record needs to:
 be sufficiently detailed and comprehensive to provide effective communication to the health care team
 provide for a client’s effective, continuing care
 enable the evaluation of a client’s progress and health outcome
 retain its integrity over time.
The NSW Privacy Committee Data Protection Principles outline the privacy principles that all NSW community services organisations must follow.
These guidelines are to protect client rights and ensure that only essential information about the client is collected.
There are a number of principles which have been developed to assist organisation to protect client rights and they are set out below:
1 Collect information directly from the client, except if:
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3
4
5
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7 a.
the client agrees otherwise b.
the other information source also follows these principles.
Make sure the client knows whether it is compulsory or optional to give the information.
Make sure the client knows the purpose for collecting the information.
Make sure the client knows who you usually pass information on to
(and who they usually pass it on to).
Make sure the client can look at and correct their information (unless the law stops this), and the client knows this right.
Make sure the information is actually needed for your purpose.
Limit your use of the information to: a.
the purpose you collected it for b.
other purposes with the client’s consent c.
preventing harm to the client or someone else.
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Make sure the information is accurate, up-to-date and complete.
Make sure the information is protected from unauthorised access.
10 Make sure the information is kept for no longer than necessary for the purpose it was collected for.
11 Make sure that the information is only used or disclosed with the freely given, clear written consent of the client if the information concerns their: a.
ethnic or racial origin b.
political opinions c.
religious or philosophical beliefs d.
trade union membership e.
health f.
sexual life.
You can get more information from Lawlink NSW: A Brief Summary of the
Information Protection Principles available at: http://www.lawlink.nsw.gov.au/lawlink/privacynsw/ll_pnsw.nsf/pages/PNS
W_03_dpps
When storing and maintaining confidential information, it is essential to keep legal requirements in mind. Ignorance of the law is never an excuse.
Because legal requirements change and are often very issue specific, all health support or aged care workers should make it a priority to find out what the requirements are for the area in which they work.
Also, different government departments produce circulars or documents that outline the legal requirements for their staff in relation to storing and maintaining information. Your agency or department should be able to provide you with the relevant documents.
Generally, case notes should be kept for seven years after the last entry. In some medical settings however, they have to be kept for 15 years after the last entry. Notes on people under the age of 18 years also have to be kept for
15 years after that person reaches 18.
Care facilities and their employees have a responsibility to ensure that statutory requirements are adhered to in regard to access, privacy, maintenance and storage of comprehensive care records.
Community services documentation and health documentation can be subject to close and careful scrutiny during civil (allegations of negligence) and criminal legal proceedings and therefore must reflect a professional approach. Care reports must meet specific standards and health support or aged care workers must take responsibility for writing professional care reports whilst being mindful of the purpose for which they are used.
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It must be:
 accurate
 objective
 legible
 brief and complete.
Written records are ‘legally accountable’ and therefore the person who gives the care must record their actions or observations factually. This ensures both the client and the health support or aged care worker are protected.
Things NOT to do:

Do not use yellow sticky notes.

Do not write in pencil.

Do not erase entries.

Do not leave spaces between entries to write things in later.

Do not cross out information so that it cannot be read.
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Do not write something on behalf of someone else.
Record all the important issues but do not ‘pad out’ the record with nonessential information. Reports need to be completed within identified timeframes and meet the legal requirements of the state in which you are working.
Aged care and health support workers often need to gather and record information about a person to assist in the development, monitoring and evaluation of service plans. Be observant, this will help in the early identification of potential problems. Document needs and problems but especially document any changes in the client and/or variations in normal service delivery.
Client files are often used to collect and store information which is subject to privacy and confidentiality. Only authorised people caring for the client have access to the files. The information written in these files are regularly monitored and evaluated.
Health records are important for all health support and aged care workers.
It is essential that they completed according to legal requirements and the standards of the organisation. Doing this provides protection for the client staff completing the documentation and also for the organisation.
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Errors must be corrected. The original and incorrect entry must still be legible after the correction. The health support or aged care worker making the correction should rule a single line through the incorrect entry, and sign their initials at the beginning or end of the line. The correct information is then written legibly next to or immediately below the error.
There are to be no spaces between individual health support or aged care worker reports. This ensures that information cannot be added at a later stage.
What not to do when you make a mistake:

Do not use correction fluid (white out) to correct errors – it could look like something is being hidden.

Do not use water soluble ink (for example felt tip pens), red or blue pens or pencils.
What to do when you make a mistake:

If you make a mistake, cross a line through it making sure that the original entry can still be read and initial that entry. Make sure the original entry can still be read.
It’s all very well to say that a record must be accurate, but what does that mean exactly? If three people see something happen, you will generally get three different versions of the one event. What do you think may make a record accurate?
There are a number of things that ensure a record is accurate and they are outlined below.
It is very important that records are accurate at all times and completed in identified timeframes and that entries are made as soon as possible after the care has been provided.
Things to do:
 ensure the client’s name is on all pages
 check the client’s name on the record before making an entry
 write date and time on all entries
 make sure entries are in chronological order. That is, date and time of reports must follow on, with no gaps between reports
 document what you observe and do for the client
 be brief and complete about issues relevant to the clients’ support
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 document events and observations as they occur to minimise confusion of the events.
Things not to do:
 do not write reports on behalf of other workers
 do not use abbreviations which are not widely accepted or approved by the organisation.
 do not use words you do not know the meaning of
 do not document events witnessed by others as factual if you did not witness the event yourself.
Ensure your reporting is accurate. For example, do not write, ‘Mr Miller was assaulted by another client’ if the correct entry should read, ‘Mr Miller stated he was assaulted by another client’.
Things to do:
 write the documents clearly
 printing may be an alternative when handwriting styles are not easy to read.
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Write reports in ENGLISH
 draw lines through errors using a ruler and initial the change—the original incorrect record must remain readable
 document using a black ballpoint pen—felt tip pens may result in smudging
 use correct spelling, punctuation and grammar at all times when documenting.
Things not to do:
 do not use correction fluid to correct errors
 do not use water soluble ink, red or blue pens or pencils
 do not use SMS or text abbreviations such as ‘tolr8d brkfst’.
Things to do:
 consider the readers of your documents
 check previous entries for continuity of support and follow-up action
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 consider the purpose of your records, eg are you reporting what you have observed or found, are you presenting ideas or recommending actions be taken
 ensure the entries cover all changes that have occurred during your shift.
All client information should be stored and maintained in accordance with organisational protocol and procedures that are based on legislation, in particular the Health Records and Information Privacy Act 2002, Privacy
Amendment Act (2000) and the National Privacy Principles (1988).
The above legislation can be accessed using the following website links:
Health Records and Information Privacy Act (2002): accessed from: http://www.lawlink.nsw.gov.au/lawlink/privacynsw/ll_pnsw.nsf/pages/PNS
W_03_hripact
Privacy Amendment Act (2000) accessed from: http://www.comlaw.gov.au/comlaw/Legislation/Act1.nsf/0/3E8F716C0779
E822CA256F72000B40F8?OpenDocument
National Privacy Principles (1988) accessed from: http://www.austlii.edu.au/au/legis/cth/consol_act/pa1988108/sch3.html
Care records are working documents that must be accessible to all authorised health support or aged care workers when required for the care and management of the client, however, a system needs to be in place for their secure filing, storage and retrieval. The policies and procedures, which guide workers, cover issues such as documentation, the maintenance of confidentiality, methods of filing and retrieval.
Release of information and removal of records from the organisation should only be allowed in response to a search warrant, subpoena or written authority from the Coroner. Policies and procedures provide security safeguards in organisations to protect the information of individuals. It is
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your responsibility to become accustomed to the policies and procedures of the organisation you work for.
Only those persons directly involved in the residents’ care should have access to personal information contained in their health record. This information is to be kept strictly confidential, at all times. As a health support or aged care worker you will, in the course of your duties, become aware of privileged information. Such information that may be gained is strictly confidential and is not to be discussed inappropriately within the organization or elsewhere. To do so is not only unethical, it is also unlawful.
Confidentiality is the protection of personal information. Confidentiality applies to all information that a client or colleague tells you verbally or gives you in writing. It also applies to things that you learn through observation. All information in a person’s health care record is confidential and may not be disclosed without permission from the client or their guardian.
Confidentiality is a critical aspect of your duty-of-care.
Remember that all clients have the same rights as everyone else in the community, regardless of whether they have a drug and alcohol problem, a mental illness, or a physical or intellectual disability. Their confidentiality must be respected. This includes difficult clients and clients with dementia.
Unless you believe a client is at risk of serious harm, don’t share the client’s personal information with others. Respect their right to privacy.
Every organisation should have a confidentiality policy. This policy usually includes an agreement, signed by workers and volunteers to uphold client confidentiality. There is usually also an authority, signed by the client, allowing you to discuss their personal information with specified others, but only in order to provide an effective service.
Consequently, you may be able to disclose aspects of the client’s health care record including disclosing their personal information, but only if you get their permission first.
Get permission in writing. Do not get ‘blanket’ approval. Blanket approval is where the client gives general approval for anyone in the organisation to disclose any information about them. Get approval for specific information to be shared, specify who you will share it with, and why you need to do so.
Keep a record of who had access to the information and for what purpose.
Most agencies get this permission when the client first comes to the organisation.
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Written personal information must be carefully protected. Files need to be stored safely and protected from unauthorised access.
Clients need to know how they can get access to their information. They may need to apply for this under the Freedom of Information Act, but usually community service organisations and aged care facilities have policies that allow clients direct access to information about themselves.
All health facilities including aged care facilities take a very serious view of failure to observe confidentiality as it constitutes a breach of the client’s privacy. This places both the facility and the individual concerned at risk of legal action and may constitute grounds for dismissal. When you begin working in an aged care facility or organisation regardless of whether it is residential or community based, you may be required to sign a confidentiality agreement. This statement means that it is absolutely essential to treat any personal details of medical, social or family history of a patient and any other information pertaining to the aged care facility and its operation as strictly confidential.
Think about a small community where everyone knows everyone else. As soon as someone goes into hospital everyone knows about it. You may be walking down the street or at the club having dinner and run into someone who wants to know about a client in your care. What would you do? Would you talk to them about it? They will find out the information soon enough anyway, particularly if they are related to the client.
Feedback
You have a responsibility to ensure that you maintain the confidentiality of your client, no matter whether you are at work or out in the community.
This also includes maintaining the client’s confidentiality when talking to friends and relatives of the client.
Authorised staff may discuss only matters relevant to their own function and responsibility with other authorised staff or with other entitled persons in the course of resident care. Under no circumstances are carers to discuss individual clients or their circumstance with other clients, family members or friends.
In practical terms, this means that information regarding residents may only be discussed at the following times and with the relevant people:
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 when the resident is admitted to the facility
 at handover time
 discussing with relevant others about the resident’s care in the normal course of your duties
 asking or answering a question about resident care with your supervisor
 reporting a change you have observed.
Do not even have general conversations (unrelated to care) about clients/patients in:
 tearooms
 lifts
 car parks
 stairwells
 earshot of other clients, the general public, domestic, kitchen, or maintenance staff (unless relevant to their care)
 close proximity to an active telephone conversation (as the person on the other end of the phone call could hear confidential information relating to a client).
Discussion of matters surrounding a client’s care should only be done for the purpose of administrating care and not at any other time.
Information may only be released in accordance with statutory and legal requirements and record handling should respect the privacy of clients at all times. Ensure you follow your organisation’s policies and procedures in relation to release of information by telephone, faxing of clinical information or the use of e-mail.
When faxing sensitive information, use a cover sheet that includes a confidentiality note. Thermal paper faxes should always be photocopied before filing in any records because the print on thermal paper fades over time. Confidential records should only be faxed from one organisation to another in exceptional circumstances, and then only if the receiving institution can guarantee the confidentiality of the information provided.
Personal information is often collected and used to plan relevant treatment and care for the individual. Personal information may also be discussed, when legally required, for instance, when providing data to the NSW
Department of Health or the Australian Government Department of Health and Ageing. Reasonable steps must be made to make sure that the personal information collected, used or disclosed is accurate, complete and up to date, and remember, privacy and confidentiality of personal information must be respected at all times.
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It is most important that the person consents to information being shared about them. Having the person or a responsible person sign a consent form acknowledges that permission has been granted to do so.
Remember, only authorised persons may:
 access client information
 use client information
 disclose client information.
The only people a health record should be made available to are:
 the person to whom the record relates or their legal representative.
Note: a health care professional should be available to assist with interpretation of the information contained in a health care record
 health support or aged care workers currently involved in the provision of care or professional advice for the client
 others under limited circumstances, in accordance with legislation and common law.
Here are some tips to help you maintain confidentiality in the workplace:
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Never give client information over the phone. If unsure, refer the call to your supervisor
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Keep your voice down especially when speaking with clients to reduce the likelihood that other clients will hear you
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Be particularly careful when speaking to the client’s family member or friend. Ensure you know who they are and what you are permitted to say and not say
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Clients are permitted to read their own files but this should only in the presence of an RN, doctor or supervisor. Ensure you know what your organisation’s policies are regarding this.
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Keep client charts, computer screens and information out of view of the public
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Persons privileged to access the client’s record should be specified and procedures developed which include supervised access by clients to their own records.
Confidentiality is not just about health records, it also applies to names and addresses of clients or residents, phone numbers and addresses of staff and volunteers, names and personal details of people who donate money or time, details of funding agreements and information about strategic planning.
Upholding confidentiality and security involves keeping information and documents in a place that can’t be easily accessed by non-authorised people.
Filing cabinets that are locked, rooms that are locked, passwords on computers and drawers that are locked are examples of secure places.
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Talking about clients in a private and soundproof place or not using their names are other ways of respecting security and confidentiality.
Clients must give permission, (preferably in writing), for information to be released to another person. In the case of a deceased person, consent may be gained from their executor. Where a client is unable to give consent due to an irreversible medical condition or a cognitive disability eg dementia, then the person’s guardian or legal representative may give consent.
Think about the computer you use and the information you store on that computer. Can anyone access your information? How do you ensure the information is secure? What do you think organisations need to consider when information is stored electronically?
Feedback
Organisations now tend to store more and more information electronically.
Sometimes they store information in hard copy as well as electronically.
Organisations have a responsibility to ensure the information is secure, easy to access and well maintained.
Increasingly community service organisations are storing information electronically. Storing information electronically saves paper, storage costs, and provides easy and secure access for a number of staff. Like a manual system however, there is a need to have an organised way to store and access the information. Some organisations now have sophisticated systems of storing information including shared files and an intranet. Whether you are working in a small or a large organisation it’s vital that there is a system for storing information that all staff understand and can access.
Sometimes organisations will allow staff to access the internet, however they will often restrict the sites that can be accessed and may also set up a system to track staff access. There is usually information regarding the organisation’s electronic system in the policies and procedures manual. It is important to know what your organisation’s guidelines are because the
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© NSW DET 2009 organisation is within their rights to discipline any staff member who does not follow their guidelines. Inappropriate access to internet sites has led to people being relieved of their position and in some instances, losing their job.
You will need to know or be able to learn how to set up electronic files, save them and put them in folders. Most organisations now use individual passwords for staff to access a stand alone computer or the organisation’s computer network. This ensures security of information. If an organisation expects you to store information on the network it is important that you understand the difference between saving on the computer ‘c’ drive and saving to a drive on the network. If you are unsure of this, make sure you discuss this with your supervisor.
You also need to consider the rights of clients regarding access to their information. Does the person require computer literacy to access their information or are they reliant on a worker for their password? This is where hard copies are useful as a backup.
The health care record needs to retain its integrity over time. To ensure this, these steps must be taken:
 it should be stored in a secure dry place
 it should be written in black ball point pen (Australian Standard AS
2828 5.1.6 pp.6) so that the record does not smudge or fade
 thermal paper faxes should always be photocopied before filing in clinical records because the print on this type of paper fades over time
 entries must not be erased or deleted eg using correction fluid.
At a basic level, health support or aged care workers are often expected to create a file, save it and then access it again to make changes to it. Once you can do this, it makes writing so much easier. It is important however, that you follow your organisation’s guidelines regarding creating files, as sometimes, if you create a folder or document in the wrong place on a computer, access restrictions may not apply. Remember, if you are not sure about what to do when creating a file, discuss this with your supervisor.
When you deal with confidential information that you are storing on computer or network, it is important that you have a password. This means that someone else cannot access the information on your computer. Try and think of a password that someone else would not guess easily. Do not leave the password written on a piece of paper stuck to your computer or on a noticeboard near your computer. This is an invitation for unauthorised
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34 people to access your work or documents. In case you forget what your password is it’s a good idea to write down your password in a private place that only you know about.
You should never access a computer using someone else’s name and password and you should never allow someone else to use your name and password to access information. Many organisations can track who has used a computer and when this has occurred. If you have allowed someone to use your password, you will have to take responsibility for any inaccuracies or inappropriate access.
Your organisation will have a policy on backing up information. You may be required to back up your information. Alternatively, there may be someone in the organisation whose role is to regularly back up information on all computers. Most organisations would be backing up at least once a week and often it will be more regular depending on the nature of work undertaken in the agency or organisation. Often organisations back up off site, away from their main office, or they may arrange for another organisation to do this on their behalf. This adds another level of security in case of a fire for example.
When there are a number of people in an office or in a number of offices/locations an internal system to access and manage files is often adopted. This is called an intranet and is different to the internet. An intranet is an internal website that stores organisational information. It is usually only accessed by staff of the organisation that have been provided with a password to the system. An organisation’s intranet may contain guidelines, policies and procedures, forms, minutes of meetings and newsletter.
A great way to store information that once was put in bulky directories is to use a database such as Microsoft Excel or Access. Databases are flexible and can be updated easily. There is often one person in the organisation responsible for updating the database.
Databases might include information about:
 local community organisations
 members of the community organisation
 clients
 staff education and training.
Confidentiality is very important with regards to databases.
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You need to have a system of naming files within folders so you can find your files. Like a filing cabinet you need to have drawers and folders within the drawers that are clearly labelled so you can find information. When there are multiple users of computers and files it is essential that the file names are clear and ordered. Some organisations use a letter and numbering system to store their electronic files and documents while others have a series of clearly identified words.
Most organisations will have a Service User File which holds important information about the person such as their profile and medical history. The following documents should be placed in the appropriate section of this file:
 individual plan
 any consent forms
 reviews
 medical review.
These documents should be kept accurate and up to date as changes occur.
Even within these folders there may be other sub-folders. Sub-folders are simply another folder within a folder.
If the agency has a network you may find that some files are stored on the network while others may be stored on individual computers. As previously discussed it is important to follow your organisation’s guidelines regarding creating folders and other files.
In summary, clinical records serve the following functions. They:
 provide detailed individualised information about how to care for a client
 facilitate communication between health professionals and carers involved in the care and management of the client.
 record what is done, why and how. Without well written documentation in the health/service records of the client, there is no proof that the client has been cared for properly. Documentation is the organisation’s evidence that care has been provided.
 provide effective ongoing care
 protects the legal interests of the organisation
 are the main source of information required for continuous improvement efforts of the organisation. It is a way to review and assess care given by carers.
 enable complete and precise client information to facilitate the allocation of proper funding levels.
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All carers and treating health professionals are responsible for documenting all the care and services provided for a client. You will find a list of these responsibilities and job descriptions in the Procedure Manuals of your workplace. Generally you will find written in your Job Description, a statement regarding your duty of care to contribute to relevant forms and written reports according to the organisation’s requirements. Not complying with this requirement could constitute a breach of care which is a very serious matter.
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